Case Management Treatment Plan for Active TB Disease

Transcription

1 Case Management Treatment Plan for Active TB Disease The purpose of this form is to provide a checklist to organize the gathering of information in a TB case to ensure the best medical and public health practices. Corresponding TB forms, both required and recommended, are listed with each component. ( * denotes forms that are required by the state of Montana) Patient Name Date Patient s contact information 1. Confirmed/Suspected Report of TB Disease* 2. TB Case Monthly Report* Assignment of responsibilities 1. Confirmed/Suspected Report of TB Disease* 2. TB Case Monthly Report* 3. TB Contact Investigation Report* 4. DOT Treatment Record 5. TB Diagnostic Referral Form Patient educator s name & dates of education 1. Monthly TB Patient Assessment 2. Treatment of Active TB Education Form Method for prevention of transmission 1. Home Isolation Agreement Planned course of antituberculosis drug therapy 1. Confirmed/Suspected Report of TB Disease* DOT plan 2.TB Case Monthly Report* 3. DOT - Treatment Record 4. DOT Agreement Estimated date of completion of treatment 1. Confirmed/Suspected Report of TB Disease* 2. TB Case Monthly Report* 3. DOT - Treatment Record Test results from initial medical evaluation 1. Confirmed/Suspected Report of TB Disease* Medical history 1. Confirmed/Suspected Report of TB Disease* 2. TB Case Monthly Report* 3. Monthly TB Patient Assessment

2 Diagnosis 1. Confirmed/Suspected Report of TB Disease* 2. TB Diagnostic Referral Form 3. Bacteriology Data Sheet Baseline tests, monitoring of activities, 1. Confirmed/Suspected Report of TB Disease* Drug therapy & side effects 2. TB Case Monthly Report* 3. Monthly TB Patient Assessment 4. DOT Treatment Record 5. DOT Adverse Reactions & Side Effects 6. Bacteriology Data Sheet 7. Biochemistry Data Sheet Potential drug interactions 1. TB Case Monthly Report* 2. Monthly TB Patient Assessment 3. DOT Treatment Record 4. DOT Adverse Reactions & Side Effects Potential treatment adherence obstacles 1. TB Case Monthly Report* 2. Monthly TB Patient Assessment 3. DOT Treatment Record 4. TB Home Evaluation 5. Treatment Active TB Education Form Personal service needs & social services referrals 1. Monthly TB Patient Assessment 2. TB Home Evaluation Referrals for social services 1. Monthly TB Patient Assessment 2. TB Home Evaluation Ensuring completion of treatment 1. DOT Agreement Incentives, enablers, adherence 2. DOT Treatment Record 3. Monthly TB Patient Assessment 4. Treatment of Active TB Education Form Intermediate & expected outcomes 1. TB Case Monthly Report* Sputum & culture conversion 2. Monthly TB Patient Assessment Symptom improvement 3. DOT Agreement MT DPHHS 4/2007

3 TB DISEASE MONTHLY PATIENT ASSESSMENT Name: DOB: Date of Visit: Interpreter: Location of visit: Home Office Other Case conference last done on: Type of TB: Pulm. TB Date Of Last CXR: Extra-pulm. TB Site: Improved: Currently infectious Stable: Worse: Other Medical Conditions Medications / Changes Education None Asthma Cancer COPD Diabetes ESRD GI Hep C / Hep B HTN Liver Pregnant Other: Tobacco use Cessation Counseling Assessment Weight: B/P: Pulse Oximetry : % LMP: AFB: Sputum Urine Other Last date submitted: Due: Containers given for (date): Problems: Lab work drawn: HFP CMP CBC Other: Vision check: Distance: Rt. L. Both: Glasses: Color vision all plates seen: Problems: Hearing screening: Results: Balance: WNL ABN Anti-coagulants Anti-hypertensives Coumadin HIV meds Immunosupressives Insulin Oral Hypo-glycemics Other: Reactions to Meds Hepatotoxicity INH,RIF, EMB, PZA Jaundice Y /N Fever Nausea Light stools Vomiting Dark urine Abd. Y/N Hypersensitivity INH,RIF, EMB, PZA Rash Arthralgia Non specific INH,RIF, EMB, PZA Headache Malaise Fatigue Anorexia Neurotoxicity INH, EMB Paresthesia Dizziness Visual changes Distance Hemolytic RIF Bruising increase Bleeding gums Hematuria Hematochezia DX, Infection Vs. Disease Transmission/Prevention Meds: Resistance/Side Effects General health care HIV/AIDS information Counseling & testing TB & HIV Diagnostic Procedures Community Resources Other: Psychosocial Alcohol / Drug use Behavioral / Mental Health Homeless Language barrier Cultural barrier Limited cognitive skills Transportation Long work hours No insurance Inadequate food/income DOT # Missed doses in past month Problems: Referrals: Nurses Comments: Re-interviewed for more contacts Comments: PHN Signature: Date: MT DPHHS 2/2007

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5 MONTHLY TUBERCULOSIS CASE REPORT Submit 1 st day of every month- new information from last report only Today s Date: Department of Public Health & Human Services TB Program Submitted By: Cogswell Building, Room C Broadway, Helena, MT Agency: Phone: ; Fax: Phone: This Report is being submitted for: Month Year Patient Name: City: County: Diagnostic Update: Sputum Conversion: Collect until 3 consecutive negative results Test AFB Smear AFB Smear AFB Smear AFB Smear AFB Smear Date Collected Result Test Date Collected M.tuberculosis Culture M.tuberculosis Culture M.tuberculosis Culture M.tuberculosis Culture M.tuberculosis Culture Result X-Ray: Date: Result: HIV: Date: Result: Other Tests: Date: Result: Most Recent Medical Exam: Date: Result: Symptoms: ( ) Cough ( ) Productive cough ( ) Fever ( ) Night Sweats ( ) Chest Pain ( ) Weight Loss ( ) Other, specify: Hospitalization: Date: Admitting Diagnosis: Medication - Treatment and Adherence: DOT Plan (describe) Self-Administration: Breaks in Therapy: (give specific date, doses, reason) List medication side effects: Medication Isoniazid -INH Rifampin - RIF Pyrazinamide - PZA Ethambutol - EMB Other: Dose Date Started Projected Length of Therapy Date Treatment Completed Date Meds Dc d and reason e.g. side effects, resistance, moved Therapy Completed & Case Closed: (This will be the final report) MT DPHHS 2/2007

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7 LTBI MONTHLY PATIENT ASSESSMENT (LATENT TB INFECTION) Name: DOB: Date of Visit: Interpreter: Location of visit: Home Office Other Case conference last done on: Other Medical Conditions None Asthma Cancer COPD Diabetes ESRD GI Hep C / Hep B HTN Liver Pregnant Other: Tobacco use Cessation Counseling Assessment Weight: B/P: Pulse Oximetry : % LMP: Other: Chest X-ray: date Lab work drawn: HFP CMP CBC Other: Medications / Changes Anti-coagulants Anti-hypertensives HIV meds Immunosupressives Insulin Oral Hypo-glycemics Other: Reactions to Meds Hepatotoxicity INH, RIF, EMB, PZA Icterus Y /N Fever Nausea Light stools Vomiting Dark urine Abd. Y/N HypersensitivityINH,RIF,EMB,PZA Rash Arthralgia Non specific INH, RIF, EMB, PZA Headache Malaise Fatigue Anorexia Neurotoxicity INH, EMB Paresthesia Dizziness Visual changes Distance Hemolytic RIF Bruising increase Bleeding gums Hematuria Hematochezia Education DX, Infection Vs. Disease Meds: Resistance/Side Effects General health care HIV/AIDS information Counseling & testing TB & HIV Diagnostic Procedures Community Resources Other: Psychosocial Alcohol / Drug use Behavioral / Mental Health Homeless Language barrier Cultural barrier Limited cognitive skills Transportation Long work hours No insurance Inadequate food/income DOT # Missed doses in past month Problems: Referrals: Nurses Comments: PHN Signature: Date: MT DPHHS 2/2007

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9 TB Case Management Monitoring Record (4/2003 sample) Case name: DOB Rec # LHD or PMD Phone Fax Diagnostic Evaluation: Symptoms (circle all) Date cough started: Cough, Sputum: thick/thin, color:, Hemoptysis, Fever, Night Sweats, Malaise, Wt.Loss of lbs Diagnostic Microbiology: Date of spec Type of spec AFB smear AFB culture Susceptibilities TST: 1. Date: 2. MM 3. ο Not done CXR 6 : TREATMENT PLAN: ο 6 MONTH ο OTHER: Pt. Wt. = (# months of treatment- NOTE: regimen & total # of doses determins when completes treatment ) Start Month 1st month 2 nd month 5 3 rd month 4 th month 5 th month 6 th month 7 th month 8 th month 9 th month INH mg RIF mg PZA mg EMB mg _ B6 mg mg mg # DOT doses: (Initial phase doses / Continuation phase doses [pt should receive all initial phase doses first]) Self Administered (Standard of care is to be on DOT: only extremely rare circumstances would justify self administered) # doses injested/mo MONTHLY MONITOR: Side effects 1 Isolation 2 Yes/ n/a _... Smear status 3 above... Culture status 4 above _... Clinical Resp 5 _... Chest X-ray mo prn...end of tx MD/clinical Evaluation 1 Side effects: = none noted, P = problem: see progress notes (symptom review, labs as ordered, visual/color while on EMB) 2 Sputum smear positive cases should be isolated until non-infectiousness is established by: demonstrate a good clinical response to treatment, AND have been on adequate TB treatment for 2 weeks, AND have 3 consecutively negative sputum smears for AFB. 3 Pulmonary cases: collect at least one monthly to document conversion to negative smear, then collect 2 nd & 3 rd to document noninfectiousness and release from isolation. Frequency of collection depends on severity of illness and diagnostic sputum smears. 4 Pulmonary cases: collect one monthly to document conversion to negative cultures 5 Clinical response: list letter code for persistent symptoms (eg/ C for cough), improved, or resolved. AFTER 2 nd mo., eval the regimen. 6 Initial: C=cavitary, Non-Cavitary:infiltrates, scaring, nodules, etc./ prn=improved, stable, worse / End= improved, stable, worse

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11 PAGE Client Name: DOB Address: Phone: I.D. Clinical Path - Dx.: Positive PPD Physician: KEY D = Demonstrates X = Done OUTCOMES/GOALS: DATE MET: U = Understands I = Instruct/Reinstruct Client or caregiver will understand disease process and screening procedures C = Complies VR = Variance Client or caregiver will verbalize understanding of significant occurrences and when to call health care provider 0 = None N/C=No Change Client or caregiver will follow-up with recommended medical care within ( ) days of nursing visit Signature Initials Client or caregiver will verbalize understanding of possible complications if follow-up not obtained Client or caregiver will leave with all questions relating to condition answered Client or caregiver will verbalize understanding of importance of finishing treatment N/A = Not Applicable / = Did Not Assess Date DIRECT CARE Initials Assess vital signs BP Nurse's Evaluation and Progress Notes Pulse Respirations Temperature Allergies: Screening tests completed/results: PPD results mm Date: Chest x-ray Liver function Visual Acuity Sputum culture/gram stain/sensitivity Assess risk factors: Medical conditions, including HIV Living arrangements/low income Contact with people with active TB Immigrants Illicit drug use Elderly or child < 4 years Occupational exposure Assess relevant psych/social dimensions: Insurance/income to cover screening & treatment Able/willing to comply with treatment Assess for s/ s of medication side effects: Loss of appetite Dark colored urine Jaundice Rash/itching Blurred vision

12 Medication side effects (cont): Date Nurses' Evaluation and Progress Notes Unusual pain in hands/feet/joints Headache Dizziness/Drowsiness Nausea/Vomiting Convulsions General tiredness Assess for s/s of active TB: Cough Hemoptysis Chest pain Fatigue/malaise Weight loss Fever/night sweats INSTRUCTION AND INFORMATION Prevention recommendations: Finish medications Testing contacts Vitamin B6 Future PPD/x-rays Educational materials discussed and given: S/s of active TB Medication sheets Signs and symptoms of complications Active vs latent TB Referrals made to: Physician HIV testing Follow-up appointment kept with/date: Medications (list) and DOT (as applicable): Confidentiality of Records per protocol Informed Consent per protocol Next PHN visit or follow-up call posppd.wpd 11/98

13 Tuberculosis Treatment Record Directly Observed Therapy - DOT Patient Name: Public Health Nurse: _ Agency: Physician: Pharmacy: Prescription: Date Place of Visit Prescribed Medications Oral meds/dosage INH RIF PZA EMB *Adverse Reactions Client Incentives PHN Signature * Adverse reactions = record on Monthly Assessment Form & consult with MD ASAP MT DPHHS 2/2007

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15 Tuberculosis (TB) Directly Observed Therapy Agreement To: Patient name D.O.B.: Because it is very important that you follow the doctor s orders so that you are cured of TB, you are being placed in a supervised treatment program by your physician and the County Health Department. This program requires that you: Take your TB medicine while being observed by the Public Health Nurse or other designated staff as indicated below (days, time, and location): LOCATION: DAYS: Monday Tuesday Wednesday Thursday Friday (circle 2 days if bi weekly) TIME: a.m. / p.m. We want to help you get better as quickly as possible and to protect those around you from getting TB. If you do not follow these directions for treatment, your condition could worsen and you could spread the disease to others. If you do not continue supervised treatment, the County may pursue legal action against you, which if convicted, may result in court ordered detainment for your treatment. PHN or Designee Signature Date I have read the above information, understand it, and agree to the conditions. Patient s Signature Interpreter Signature (if needed) Date Date Copy given to patient (PHN or Designee Initials) MT DPHHS 2/2007

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17 DIRECTLY OBSERVED THERAPY RECORD Attachment C Name of Patient: Isolation Residence: Date Time Medication Given Comments (List any other meds given, and/or if contact was attempted and patient wasn t home) Θ Pyrixodine (B 6 ) Staff Signature

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